Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey

Objective:Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. Patients and Methods:A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. Results:The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. Conclusions:The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.

[1]  E. Pravinkumar.  Obesity in general elective surgery , 2003, The Lancet.

[2]  D. Lu,et al.  Donor and recipient outcomes in right lobe adult living donor liver transplantation , 2002, Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society.

[3]  L. Sharples,et al.  A case-control analysis of readmissions to the cardiac surgical intensive care unit. , 2002, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[4]  Robert C. G. Martin,et al.  Quality of Complication Reporting in the Surgical Literature , 2002, Annals of surgery.

[5]  J. Bruce,et al.  Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery , 2001, The British journal of surgery.

[6]  J. Takala,et al.  Outcome and resource utilization in gastroenterological surgery , 2001, The British journal of surgery.

[7]  P. Pronovost,et al.  Variations in complication rates and opportunities for improvement in quality of care for patients having abdominal aortic surgery , 2001, Langenbeck’s Archives of Surgery.

[8]  E. Targarona,et al.  Complications of laparoscopic splenectomy. , 2000, Archives of surgery.

[9]  S. Williams,et al.  Complexity‐ and risk‐adjusted model for measuring surgical outcome , 1999, The British journal of surgery.

[10]  J. Daley,et al.  Risk factors for prolonged length of stay after major elective surgery. , 1999, Annals of surgery.

[11]  S. Lemeshow,et al.  European system for cardiac operative risk evaluation (EuroSCORE). , 1999, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[12]  P. Breslau,et al.  Recording and classification of complications in a surgical practice. , 1999, The European journal of surgery = Acta chirurgica.

[13]  A. Gawande,et al.  The incidence and nature of surgical adverse events in Colorado and Utah in 1992. , 1999, Surgery.

[14]  F. Grover,et al.  The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. , 1998, Annals of surgery.

[15]  C. Camargo,et al.  Effect of postoperative complications on health and employment following liver transplantation. , 1998, Clinical transplantation.

[16]  S. Ferraris,et al.  Operative outcome and hospital cost. , 1998, The Journal of thoracic and cardiovascular surgery.

[17]  A. Barkun,et al.  Measuring postoperative complications in general surgery patients using an outcomes-based strategy: comparison with complications presented at morbidity and mortality rounds. , 1997, Surgery.

[18]  J. Pomposelli,et al.  Surgical complication outcome (SCOUT) score: a new method to evaluate quality of care in vascular surgery. , 1997, Journal of vascular surgery.

[19]  D. Candinas,et al.  Preoperative risk assessment in elective general surgery , 1996, The British journal of surgery.

[20]  T. Ferguson,et al.  The additional hospital costs generated in the management of complications of pacemaker and defibrillator implantations. , 1996, The Journal of thoracic and cardiovascular surgery.

[21]  P. Mcaleese,et al.  The Effect of Complications on Length of Stay , 1994, Annals of surgery.

[22]  P. Clavien,et al.  Definition and Classification of Negative Outcomes in Solid Organ Transplantation Application in Liver Transplantation , 1994, Annals of surgery.

[23]  R. Tibshirani,et al.  Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors. , 1992, Annals of surgery.

[24]  C. Sherbourne,et al.  The MOS 36-Item Short-Form Health Survey (SF-36) , 1992 .

[25]  J. Sanabria,et al.  Proposed classification of complications of surgery with examples of utility in cholecystectomy. , 1992, Surgery.

[26]  L. Mason,et al.  Hospital costs of surgical complications. , 1984, Archives of surgery.

[27]  W. Henderson,et al.  Risk-adjusted surgical outcomes. , 2001, Annual review of medicine.

[28]  S. Nashef,et al.  Eurp-pean system for cardiac operative risk evaluation (Euro SCORE) , 1999 .

[29]  O. Rønning,et al.  Stroke units versus general medical wards, I: twelve- and eighteen-month survival: a randomized, controlled trial. , 1998, Stroke.

[30]  Ware J.E.Jr.,et al.  THE MOS 36- ITEM SHORT FORM HEALTH SURVEY (SF- 36) CONCEPTUAL FRAMEWORK AND ITEM SELECTION , 1992 .